It’s going to take more than a few tweaks to fix primary care, says Rushika Fernandopulle, M.D. He’s not bothering with that small-scale approach. Eight years ago he co-founded Iora Health, the Boston-based startup that is building new primary care practices from scratch.
One of his favorite stories explains why he’s trying to turn primary care on its head. He recalls a patient who came to his practice. “She was a hot mess,” he says. Her hair was disheveled, she was overweight, she wasn’t taking her medications and her hypertension was out of control.
As well as seeing a doctor, she began working with a health coach and coming to group sessions for patients. Six months later, one of the doctors told Fernandopulle she was in the office and he had to see her.
“I go in, and she’s a different person,” he says. Her hair was combed, there was a glint in her eyes, she had lost weight, she was taking her medications, her blood pressure was under control and she was back to work, he said.
“I said, ‘You look amazing. What have we done to help you?' And she said something very profound,” Fernandopulle says. She didn’t talk about the practice’s great IT program, or protocols or doctors.
“She said, ‘You all cared about me, you taught me to care about myself and I didn’t want to let any of us down.' That’s what causes people to change behavior,” Fernandopulle said. “What we’ve been able to do by restoring humanity to healthcare is to allow that to happen.”
Here's more about Fernandopulle and what he had to say during a recent conversation:
FierceHealthcare: You’ve been described as a startup physician CEO, a doctor who is passionate about healthcare and willing to step out of the system as we know it and be an innovator. How are you shaking up primary care?
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Rushika Fernandopulle: About 15 years ago when I started doing this, the insight was that there’s a vision of what we think primary care ought to be. It’s radically consumer-centric, it’s team-based, we leverage digital tools, it’s value-based. To summarize, it’s a system based on relationships and not transactions. The problem is our system is not built on those things. It’s fragmented, it’s reactive, it’s take-a-number. What everyone else was doing was trying to take the existing system and tweak it little by little to try and get to this vision of where we want to go. I think I was just impatient, [I thought] that maybe what we need to do is simply build the place where we want to go and create the vision of where we want to be. Eventually, we’ll figure out how to get from here to there. So that was the journey with Iora and even before that. How do we build primary care that is the way it ought to be done?
FH: What are you trying to accomplish with Iora, which is far from a traditional primary care model?
RF: Our mission is to restore humanity to healthcare. We want to build a different vision of what primary care looks like that actually accomplishes that. We do it by actually building new practices from scratch. Obviously, we had to change the payment model. We work with self-insured employers, but largely we found a lot of traction in working with Medicare Advantage insurers. We get paid not for things we do, but in a value-based way, where we get paid more for keeping people healthy.
FH: And how do you do that?
RF: We build new practices in neighborhoods and have really robust teams of people to help patients execute on the plan. Of course, it includes doctors, like myself, whose job it is to diagnosis and prescribe. But the hard part about primary care and healthcare, in general, isn’t about someone telling you what to do, it’s how you execute on the plan. In my old practice, I often joked that people come to me in my seven-minute visit and all I could do is tell them, ‘You should eat less, exercise more, take your medicine and good luck, sucker.’ In three months, they would come back [and hear], ‘You bad, bad patient, you didn’t do that.’ What we ought to do is help people actually do this.
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FH: Have you found a solution?
RF: That’s why we have these folks we call health coaches. They are from the community, they speak the language of the people they serve and they are picked for empathy. Their job is to really help patients execute on a plan. They hold their hand when it is the right thing to do or sort of kick them in the heinie when that’s the right thing and educate them about their health. We have learned we have to integrate behavioral health into our practices, so we have behavioral health specialists. We have to focus on social determinants of health, so we have folks helping with the social problems and barriers that keep patients from doing the right thing. We get patients together in groups, so they can help each other. We communicate by text and email and video chats. We proactively reach out to people when we think we need to. We help them navigate the system and find the right specialists and co-manage in the hospital. If it sounds a little different than the typical practice, it’s completely different.
FH: What about using digital tools?
RF: We decided we had to build a different IT platform. The electronic health records out there are really built to help you document, code and bill. They’re not built to help you improve people’s health, engage them, improve performance. We had to build our own culture. I think we’ve been able to build a very different culture—a culture of service, a culture of high-impact relationship-based care.
FH: You’ve been able to get financial support to expand—something like $240 million over the past eight years. Why are companies willing to invest?
RF: I think we’ve been able to convince people this is one of the biggest opportunities in the world. Not only to create an incredible human impact because our current healthcare system, I think, leads to poor outcomes and poor experience, but also, it’s a huge financial opportunity. We know we spend $3.5 trillion on healthcare in this country and we know about a third of it is waste—things we are doing to people that are not only non-effective, or people don’t want or need, but also can be harmful. If we can reduce those things that are wasteful we can unlock just a staggering amount of dollars and that is how we can convince people to invest.
FH: What lessons would you share with other primary care physicians?
RF: There’s a ton we’ve learned. One lesson is that there is a much better way of practice. The way we do it now is awful for patients and awful for physicians. Despite really good intentions, it leads to poor outcomes and it’s usually wasteful. We and other people who are doing this, who decided we have the courage to start from scratch and re-think the model, have created things that work just so much better. It’s a better experience for patients and a better experience for the physicians and teams. It gives better clinical outcomes and it results in dramatically lower total healthcare costs.
The second lesson is that this just isn’t a little different from what people are doing now, it’s completely different. What a lot of people in the industry are trying to do is take an existing practice and optimize on the fee-for-service model and also try to do what we are doing at the same time. That’s really hard. What a lot of people are doing is trying to move very slowly from the old world to the new world. We’re simply saying maybe we ought to go quickly.
FH: As an innovator, not everything works. What one thing would you say has been the biggest flop?
RF: There are plenty of things we try that don’t work. I would say if you are not doing things that don’t work, you’re not trying hard enough. I think there’s risk aversion in healthcare. One of the early things that didn’t work is we built these practices and we had this "Field of Dreams" model that if you build it, they will come. That is not true. Even if you create a much better mousetrap, you have to spend the time and effort to figure out how to communicate that, particularly to patients.
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FH: Tell us where you are today in terms of how many patients you care for and how many practices?
RF: Remember, we’re tiny. We have tens of thousands of patients. And we’re growing fast. We’re growing by 60% to 70% a year as we ramp up. By the end of this year, we will have roughly 50 practices in a dozen or so different markets in every time zone. We’re in Seattle and Phoenix and Denver. We’re opening in Houston and North Carolina. These are all very different markets and we’ve been able to get the model to work in all of these places.
FH: What did you think of the big announcement from the Centers for Medicare & Medicaid Services that they are launching five new funding pathways for primary care? Is that encouraging?
RF: It would allow us to do this sort of care with original Medicare patients. I think it is hugely encouraging. The devil, of course, is always in the details. And there are lots of details that have not been released yet. But they are saying all the things we have been saying for 15 years: We need to reinvent primary care, we need to change the payment model, we need to do all the things we are doing. We are very encouraged by it and excited about it.